Beijing medical insurance reimbursement conditions and procedures 1. Outpatient expenses (1) Reimbursement scope: The insured person will be reimbursed at the medical insurance designated hospital or specialist hospital of personal choice, traditional Chinese medicine hospital and Class A hospital (Youyi, Xuanwu, Guang'anmen Traditional Chinese Medicine, Tongren, Xiehe,

General outpatient and emergency expenses incurred by Peking University Third Hospital, Peking University People's Hospital, Peking University First, Jishuitan, Chaoyang, Jiangong, Liangxiang).

(2) Reimbursement ratio: If the total outpatient and emergency expenses incurred by employees in a calendar year exceed 2,000 yuan, the medical mutual aid fund will pay 50% for some large amounts of more than 2,000 yuan, and the individual will pay 50% out of pocket.

For retirees whose total accumulated income exceeds 1,300 yuan, the large-amount medical mutual aid fund for those over 1,300 yuan and over 70 years of age pays 70% and the individual pays 30%, and the large-amount medical mutual fund for those over 70 years old pays 80% and the individual pays 20%.

The maximum payment limit within a calendar year is 20,000 yuan.

(3) Medical treatment management: General outpatient and emergency medical expenses must be paid in personal cash. The medical expenses incurred must comply with the scope of the three major catalogs of medical insurance. When outsourcing drugs, special prescriptions must be issued in designated hospitals and stamped with medical insurance for outsourcing.

Chapter, then go to designated pharmacies to buy medicines.

(4) Reimbursement process: If the cumulative amount exceeds the minimum payment standard within a calendar year, the insured person will submit the documents to the unit or social security office. The unit or social security office will enter the documents into the enterprise version and report the electronic information and documents to the medical insurance center.

The medical insurance center completes the review, settlement, and payment within 15 working days.

(5) Application materials: general outpatient and emergency department receipts, medical insurance prescriptions (double price for prescriptions), and detailed cost of examination and treatment.

(6) Declaration date: 1-20th of each month. Fees for the current month must be declared the following month. Fees for the current year must be declared before January 20th of the next year.

2. Hospitalization expenses (1) Reimbursement scope: hospitalization expenses incurred by insured persons in medical insurance designated hospitals or specialized hospitals, traditional Chinese medicine hospitals and Class A hospitals selected by individuals.

(2) Reimbursement ratio: The minimum payment standard for the first hospitalization within a calendar year is 1,300 yuan, and 650 yuan each time thereafter.

The payment ratio is divided into three levels. Taking a tertiary hospital as an example, the rising and falling standards are: 30,000 yuan, 85% in employment, 91% in retirement, 90% in employment between 30,000 and 40,000 yuan, 94% in retirement, and 95% in employment above 40,000 yuan.

Retirement 97%.

A billing cycle is generally 90 days for hospitalization.

360 days for psychiatric hospitalization constitute a settlement cycle, and the fluctuation standard is halved.

The maximum overall fund payment within a calendar year is 70,000 yuan.

The maximum payment for major hospitalization is 100,000 yuan, and the payment ratio for major hospitalization is 70%.

(3) Medical treatment management: Please use the "Beijing Medical Insurance Manual" when seeking medical treatment.

If the unit pays the fee in full, the individual only needs to pay part of the hospitalization prepayment to go through the hospitalization procedures.

The medical expenses incurred must comply with the scope of the three major catalogs of medical insurance.

(4) Reimbursement process: When discharged, the hospital and the individual settle the self-pay and self-pay portion, and the overall fund reimbursement amount is settled by the hospital and the district medical insurance center.

3. Outpatient special diseases (1) Reimbursement scope: Insured persons who take anti-rejection drugs after radiotherapy and chemotherapy for malignant tumors, renal dialysis, and kidney transplantation are within the scope of outpatient special diseases after going through the special disease approval procedures.

outpatient medical expenses.

(2) Reimbursement ratio: The reimbursement ratio is the same as hospitalization.

The billing cycle for outpatient special diseases is 360 days.

(3) Medical treatment management: Insured persons can only choose one hospital as the designated hospital for special diseases. Please use the "Beijing Medical Insurance Manual" when seeking medical treatment.

If the unit pays the fee in full, the individual only needs to pay the personal out-of-pocket and self-pay amount, and the reimbursement amount from the overall fund will be settled by the hospital and the district medical insurance center.

(4) Reimbursement process: The insured person submits the documents to the unit or social insurance office, and the unit reports the documents to the medical insurance center.

The medical insurance center completed the review, settlement, and payment work on the same day. IV. Scope of reimbursement by Beijing’s medical insurance (1) Western medicines and proprietary Chinese medicines, in accordance with the Municipal Health Bureau’s “Notice on Issuing the Reimbursement Scope of Publicly Funded Medical and Labor Insurance Medical Drugs in Beijing” (Beijing Health Bureau)

[1997] No. 15) and the "Supplementary Opinions on the Implementation of the "Reimbursement Scope of Publicly Funded Medical and Labor Insurance Medical Drugs in Beijing" (Jingwei Gongzi [1998] No. 2) documents are implemented.

For medicines that are marked as “partially borne by the individual”, the individual must first bear 10%, and the remaining costs will be included in the payment scope of the basic medical insurance fund.

(2) Hospital preparations: According to the Municipal Health Bureau's "Notice on the Implementation of the "Reimbursement Scope of Hospital Preparations for Publicly Funded Medical and Labor Insurance Medical Care in Beijing" (Jingwei Gongzi [1999] No. 2).

(3) Payment scope and use of traditional Chinese medicine pieces 1. Traditional Chinese medicine pieces that need to be paid for by individuals shall be paid according to the Municipal Health Bureau's "Regulations on the Scope of Self-paid Drugs for Persons Who Enjoy Publicly Funded Medical Care and Labor Insurance Medical Care in Beijing" (Jingwei Caizi)

[77] No. 267) The first article of the document shall be implemented.